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D' �R SANITARY PERMIT APPLICATION <br /> In accord with ILHR 83.05,Wis.Adm.Code COUNTY <br /> • . STATE SANITARY PERMIT <br /> —Attach complete plans(to the county copy only)for the system,on paper not less than W35(0 <br /> 8%x 11 inches in size. ❑Check if revision to previous application <br /> -See reverse side for Instructions for completing this application. STATE PLAN I.D.NUMBER <br /> L APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. <br /> �Y OWNER PROPERTY LOCATION <br /> PR <br /> 70176 S+Q•∎••, @ * NE% hal%,S 3 T 1. ,N,R /7 r)W <br /> PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# <br /> 03 I CIS eh- -- <br /> STATE (ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER <br /> �o�f...�s Li 1 5392 (4/4 )6z3-314‘ ....... <br /> t <br /> d. TYPE OF BUILDING: (Check one) ❑State Owned TVILTM�LAGE' NEAREST R 3 <br /> ❑ Public 1 or 2 Fam.Dwellin of bedrooms- PRLELT2RUMiRRs �'��►►''`"'jj``,,'' <br /> IN. BUILDING USE: (If building type is public,check all that apply) Cite;,/ 7_,— 03Z— e,, E30 - <br /> 1 ❑ Apt/Condo <br /> 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility <br /> 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining <br /> 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash <br /> 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify. <br /> N. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) <br /> A) 1.❑ New 2. II Replacement 3. ❑Replacement of 4.❑ Reconn ion of 5. epair of an <br /> System System Tank Only Existing Stem '1 fisting System <br /> B) ❑ A Sanitary Permit was previously issued. Permit# — Dat4 d �6 <br /> V. TYPE OF SYSTEM: (Check only one) <j e- 0 <br /> O F fo <br /> Non-Pressurized Distribution Pressurized Distribution Experimental �0O •�4. Ot11� <br /> 11 Di Seepage Bed 21 ❑ Mound 30 ❑ Specify Type <br /> (1),. '''6 1 ❑ Holding Tank <br /> 12 Seepage Trench 22 ❑ In-Ground 1°. ❑ Pit Privy <br /> 13 ❑ Seepage Pit Pressure '�43' J Vault Privy <br /> 14 ❑ System-In-Fill <br /> VI. ABSORPTION SYSTEM INFORMATION: <br /> 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4.LOADING RATE 5.PERC.RATE 6.SYSTEM ELEV. 7. FINAL GRADE <br /> REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Mi i ) // ELEVATION <br /> "1 c!7 OL�{'S a5 4 . 14 34.40 Feet 27'0 Feet <br /> CAPACITY <br /> VII. TANK in gallons _ Total #of Prefab. Site Fiber- Exper. <br /> INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App <br /> Tanks Tanks strutted <br /> Septic Tank or Holding Tank lO, I Q60 I ►11.c. . 4 _ H ❑ O <br /> Lift Pump Tank/Siphon Chamber ❑ — <br /> VIN. RESPONSIBILITY STATEMENT <br /> I,the undersigned,assume responsibility for I .. . !ado k.f the.t Its - =ge system-*on the attached plans.Plu 's Name rin l)rji. Plumbs- PRSW No: Business Phone Number: <br /> �0 < <br /> � ( Ir S3 ( 44 )6.3-15.17 <br /> Plu 161- <br /> est; Sta Zip CociN _ , i <br /> Colt' V liti. 53C-kr <br /> IX. COUNTY/DEPARTMENT USE LY <br /> ❑ Disapproved Sanitary Permit Fee(Includes GrasWwster Data Issued Issu .• gna f•Stamps) <br /> 1►pproved ❑Owner Given Initial <br /> Surcharge Feel <br /> Owner Adverse i eMr itial pn $ MSc CD II-7-27 /4a'��Si/-. <br /> X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: <br /> SB0-6398(formerly PIb47)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber <br />